Observations
Based upon the review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in four of seven records.
The findings include:
Seven client records were reviewed on January 10, 2013. The facility failed to assure that counseling services were provided according to the individual treatment plan in records # 1, 4, 6 and 7.
Client # 1 was admitted on September 10, 2012, and was still an active client on the date of inspection. The record included a treatment plan that was signed by the client on September 24, 2012. The treatment plan specified that the client was to receive individual counseling services one to four times per month, or as needed. As per progress notes and the record of service, the facility failed to provide any individual counseling services for client # 1 from November 1-30, 2012.
Client # 4 was admitted on September 5, 2012, and was still an active client on the date of inspection. The record included a treatment plan that was signed by the client on October 5, 2012. The treatment plan specified that the client was to receive individual counseling services two to four times per month, or as needed. However, as per progress notes and the record of service, the facility failed to provide any individual counseling services for client # 4 from October 6 -31, 2012, November 1-30, 2012, and December 1-31, 2012.
Client # 6 was admitted on August 22, 2012, and was discharged on October 26, 2012. The record included a treatment plan that was signed by the client on August 27, 2012. The treatment plan specified that the client was to receive individual counseling services two to four times per month, or as needed. As per progress notes and the record of service, the client received individual counseling services on September 24, 2012. Therefore, the facility failed to provide a minimum of two individual counseling sessions for client # 6 from September 1-30, 2012, and failed to provide any individual counseling services from October 1-25, 2012.
Client # 7 was admitted on July 20, 2012, and was discharged on November 25, 2012. The record included a treatment plan that was signed by the client on August 20, 2012. The treatment plan specified that the client was to receive individual counseling services two to four times per month, or as needed. As per progress notes and the record of service, the client received individual counseling services on September 24, 2012, October 8, 2012, and November 12, 2012. Therefore, the facility failed to provide a minimum of two individual counseling sessions for client # 7 from September 1-30, 2012, and October 1-31, 2012.
The findings were confirmed by a clinical supervisor during the record review.
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Plan of Correction
NET clinical supervisors will meet with clinical staff on Tuesday February 7th, 2013, to discuss the need to clearly document the provision of Individual sessions as prescribed on the treatment plan. In the event that a client does not show up for the scheduled individual session, a DAP note documenting the client's absence will be submitted to the client record. Lastly, clinical supervisor will educate the clinical staff that, if a client does miss a scheduled individual session, then a make up session can be provided and should be noted within the documented Missed Individual Session DAP note. NET clinical supervisors will conduct weekly audits to ensure this documentation of missed or rescheduled sessions is being accurately completed as well as organize a priority list of clients who have not received the proper number of individual sessions as per the prescription of their treatment plan. |